Below is a list of printable forms to change, update, or verify information.
- Group Information Change Form – To change group contact information or add or remove a Group Administrator.
- Employer Size Verification – To change or verify your employer size for COBRA, Medicare, and market segment classification (small or large) purposes.
- Member Information Change Form – To update member information (e.g., address change, coverage termination, or employment status).
Request to Change or Verify
Employers may use this form to submit Information Change or Verification Forms and supporting documentation.
If you are not the health plan administrator, please obtain authorization from him/her to submit this request.
For assistance, contact our Billing Department.